percussion of heart

1. Azerbaijan Medical University
Department of clinical skills
Halil İbrahim ŞEFİK 220i-6a MPF2

2. Anatomy
 The heart is enclosed in the chest cavity,
within the rib cage, which allows for
identifying the approximate location of the
heart using the sternum and ribs as points of
reference.
 Roughly 1 centimeter (cm) from the right
sternal line, along the upper border of the
3rd right costal cartilage is the first point.
 Continuing to about 2.5 cm from the left
lateral sternal line along the lower border of
the 2nd left costal cartilage is the second
point, which then forms the top boundary.

3. Anatomy
 The next point is found approximately 2 cm to
the right of the sternum along the interspace
between the 6th and 7th rib on the right, where
the cartilage joins the sternum.
 The fourth and final point is found about 9 cm to
the left of the midsternal line, and corresponds
to the apex of the heart. Joining these points will
form the other 3 borders of the heart.
 The location where the 4 main heart valves can
be heard is divided into the aortic area, pulmonic
area, tricuspid area, and mitral area.

4. Anatomy
 The aortic area is found in the 2nd intercostal space to the
right of the sternum.
 The pulmonic area is found in the 2nd intercostal space to the
left of the sternum.
 The tricuspid area is found in the 4th intercostal space to the
left of the sternum, where other right heart sounds will also be
heard.
 Finally, the mitral area is found in the 5th intercostal space
along the mid-clavicular line, where left heart sounds can also
be heard.
 These 4 areas can be remembered by the mnemonic “All
Physicians Take Money” or “All Patients Take Meds”.
Alternatively, some use the mnemonic Apartment M2245 (APT
M2245), for the locations (2 right) aortic, (2 left) pulmonic, (4)
tricuspid, and (5) mitral. Another important auscultation point
is known as “Erb’s point” which is found at the 3rd left
intercostal space, along the left sternal border, between the
pulmonic and tricuspid areas.

5. Heart percussion
 Main goals of heart percussion
are:
 1. Disclosure of ventricular
and auricular dilation;
 2. Disclosure of vascular
bundle dilation.

6. Defining of relative cardiac dullness borders.
 At first right, left and upper borders of relative cardiac dullness are defined. It is necessary to
obtain beforehand an indirect impression about the level of diaphragm standing which influences
the results of percussion defining of relative cardiac dullness size. For this purpose the lower
border of the right lung is defined along the midclavicular line which is normally located at the
level of rib VI
 The right border of relative cardiac dullness, formed by the right atrium (RA), is
 found by percussing one rib above the found lower lung border (usually in the IV intercostal space),
moving vertically placed pleximeter finger strictly along the intercostal space. Normally it situated
at the right sternum edge or 1 cm laterally.
 The left border of relative cardiac dullness formed by the left ventricle (LV) is
 defined after preliminary palpation of the apical impulse, usually in the V intercostal space,
moving from anterior axillary line towards the heart. Normally it situated medial to the
midclavicular line for 1-2 cm.
 The upper border of relative cardiac dullness, formed by auricle of left atrium and pulmonary
artery trunk is defined by percussing from top to bottom, 1 cm lateral from left sternal line (but
not along left para-sternal line!). Normally it situated at the III rib level.

7. Normal borders of the absolute cardiac dullness:
right - in the IV intercostal space along the left edge of the sternum, the upper - level of the lower
edge IV R. at the left parasternal line, left - 1-2 cm medially from the left border of relative cardiac
dullness.
Changes of heart dullness borders may be caused by extra cardiac reasons. So, while high diaphragm
level heart takes a horizontal position that leads to increasing of the transverse heart size. At low
diaphragm level heart takes a vertical position, and, accordingly, its transverse size becomes less.
Pleural fluid or free pleural air in one of the pleural cavities brings to displacing of .the cardiac
dullness borders to the healthy side, atelectasis or lung shrinking, fibro thorax – to the sore side. Area of
superficial cardiac dullness sharply decreases or disappears at the emphysema and increases at the lung
shrinking.
Increase of superficial cardiac dullness area also occurs in heart ante displacement by mediastinal
tumour, pericardium effusion, right ventricle dilation. Relative cardiac dullness borders are displaced
because of the heart chambers dilation.
Relative dullness borders displacement to the right is caused by right atrium and right ventricle
dilation. Relative dullness is displaced upwards because of left atrium and pulmonary artery trunk
dilation. Relative dullness borders displacement to the left is the result of left ventricle dilation. It is
necessary to remember, that sharply dilated and hypertrophied right ventricle shoving back the left
ventricle also can displace relative dullness border to the left. Aortic dilation leads to dullness diameter
increase in the 2nd intercostal space.

8. Measurement of heart diameter.
 For measurement of heart
diameter the distances from right
and left borders of relative
cardiac dullness to midsternal
line are defined.
 Normally these distances make
respectively 3-4 cm and 8-9 cm,
and heart diameter makes 11-
13cm .

9. Defining of vascular bundle borders.
 The vascular bundle including aorta, vena cava superior and pulmonary artery
is not simple to percuss.
 Soft percussion is applied, moving vertically placed pleximeter finger along
the II intercostal space on the right and on the left towards the sternum.
 Normally vascular bundle borders coincide with right and left edges of the
sternum, its width doesn't exceed 5-6 cm.

10. Defining of heart configuration
For defining of heart configuration the borders of right and left contours of
relative cardiac dullness are additionally defined by percussing in the right III
intercostal space and in the left III and IV intercostal spaces. Having connected
all the points corresponding the borders of relative cardiac dullness, one can
obtain the idea about heart configuration. Normally an obtuse angle is clearly
defined along the left heart contour between the vascular bundle and the left
ventricle - the socalled waist of the heart.
The arc of the right contour of the heart in norm –vena cava superior– on the
edge of the sternum to R. III, right atrium in the 3-4 intercostal spaces 1 cm
outwards from the right edge of the sternum. The angles of the right contour of
the heart in norm – angle between vena cava superior and right atrium and
between the right atrium and diaphragm in the 5 intercostal space from the
sternum. The arc of the left contour of the heart in norm - I intercostal space at
the edge of the sternum - aortic arch, II intercostal space at the sternum – the
arc of the pulmonary artery, level III R. over the edge of the sternum arc of the
left atrium, below the arc of the left ventricle. The "waist" of the heart is the
angle between the vascular bundle and the arc of the left ventricle. The vertex
of this angle- left atrium auricle . With the increase of LP waist heart
''smoothed", while increasing the LV – "stressed".

11. Defining of heart configuration
Defining of heart configuration. For defining of heart configuration the borders of right and
left contours of relative cardiac dullness are additionally defined by percussing in the right
III intercostal space and in the left III and IV intercostal spaces. Having connected all the
points corresponding the borders of relative cardiac dullness, one can obtain the idea about
heart configuration. Normally an obtuse angle is clearly defined along the left heart contour
between the vascular bundle and the left ventricle - the socalled waist of the heart. The arc
of the right contour of the heart in norm –vena cava superior– on the edge of the sternum to
R. III, right atrium in the 3-4 intercostal spaces 1 cm outwards from the right edge of the
sternum. The angles of the right contour of the heart in norm – angle between vena cava
superior and right atrium and between the right atrium and diaphragm in the 5 intercostal
space from the sternum.
The arc of the left contour of the heart in norm - I intercostal space at the edge of the
sternum - aortic arch, II intercostal space at the sternum – the arc of the pulmonary artery,
level III R. over the edge of the sternum arc of the left atrium, below the arc of the left
ventricle. The "waist" of the heart is the angle between the vascular bundle and the arc of
the left ventricle. The vertex of this angle- left atrium auricle . With the increase of LP
waist heart "smoothed", while increasing the LV – "stressed".

12. Mitral configuration I -
Waist heart smoothed at the
expense of hypertrophy of the left
atrium, the vascular bundle can be
extended due to the dilatation the
pulmonary artery, it is possible to
laterally shift the right border of
relative cardiac dullness due to right
ventricle hypertrophy with the
development of pulmonary
hypertension; the reason for the
configuration is mitral stenosis.

13. Mitral configuration II -
 The reason for the configuration is mitral incompetence. Mitral valve incompetence
(insufficientia valvulae mitralis) appears in that cases when mitral valve on left ventricle
systole incompletely closes left atrioventricular ostium and blood regurgitates from the
ventricle to the atrium. Mitral incompetence may be organic and functional.
 Organic mitral incompetence more frequently appears as a result of rheumatic
endocarditis due to which connective tissue develops in valve leaflets and later on it is
wrinkled and causes shortening of leaflets and attached chordae tendinae.
 As a result of these changes valve edges during systole closes incompletely, forming a
chink through which in ventricle contraction the part of blood regurgitates into the left
atrium. Rarely wrinkling of valve leaflets and shortening of chordae tendinae develops as
a result of atherosclerosis.
 In functional or relative mitral incompetence mitral valve is not changed but it’s ostium is
enlarged and valve leaflets close it incompletely. Relative incompetence may develop
owing to left ventricle dilatation in myocarditis, myocardidystrophy, myocardiosclerosis,
when circular muscle fibers, forming muscle ring around the atrioventricular ostium
weaken, and also in papillary muscles damage.

14. Hemodynamics abnormalities
 A little narrowing of aortic orifice doesn’t cause significant circulation
alteration. If the degree of stenosis is high, during systole the left ventricle
empties incompletely, as all blood volume has no time to pass across narrow
orifice into aorta.
 On diastole normal blood volume from the left atrium adds to this residual
blood portion, that leads to left ventricle overfilling and pressure rising within
it. This abnormality of intracardiac hemodynamics is compensated by left
ventricle overwork, and causes its hypertrophy.
 On percussion the displacement of relative dullness borders to the left and
aortic heart configuration (with accentuated cardiac waist), caused by left
ventricular hypertrophy are detected.

15. insufficientia valvulae aortae
• ‘‘Aortic incompetence’’ is valve disease in which the
semilunar cusps close incompletely the aortic orifice
and during diastole blood regurgitates from aorta into
left ventricle.
• Aortic regurgitation occurs if the aortic valve ring
dilates, as a result of dissecting aneurysm, ankylosing
spondylitis or syphilis for example, or if the valve
cusps degenerate, such as after rheumatic fever,
atherosclerotic lesion or endocarditis.

16. Trapezoidal configuration of
the heart
In aortic incompetence during diastole blood comes in the
left ventricle not only from the left atrium but
regurgitates from aorta to. It causes left ventricle
overfilling and stretching on diastole. During systole left
ventricle contracts with grater force to eect into aorta
increased stroke volume. Left ventricle overwork leads to
its hypertrophy, and increase of systolic blood volume in
aorta causes its dilatation. Sharp fluctuation of blood
pressure within aorta during systole and diastole is
characteristic for aortic incompetence. Increased as
compared with normal blood volume within aorta during
systole causes increase of systolic blood pressure, and as a
part of blood volume regurgitates into ventricle during
diastole, diastolic pressure rapidly decline.The heart has a
trapezoid shape, waist of the heart, angle between vena
cava superior and right atrium and angle between right
atrium and diaphragm "disappear'' the reason of
configuration is hypopericardium.

17. Drip" configuration
of the heart -
The left and right border of cardiac dullness is
shifted medially, the area of cardiac dullness
is diminished, the heart becomes "drip" form,
cause - emphysema of the lungs.

18. Thanks for your attention 

19. References
 https://www.kenhub.com/en/library/anatomy/percussion-and-auscultation-
of-the-heart
 https://www.ulsu.ru/media/documents/Internal_diseases_propedeutics._Part
_II._Diagnostics_of_cardiovascular_diseases.pdf